MEDICARE: CRYSTAL WADE APRN-CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	913829	TX
2	163W00000X	Registered Nurse	1015357	OR
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	1216753	TX

General Provider Information

NPI Number	:	1548056542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL WADE APRN-CNP

Provider Business Mailing Address
First Line	:	214 KIMBERLY DR
Second Line	:
City	:	CONVERSE
State	:	TX
Zip	:	78109-1530
Country	:	US
Telephone Number	:	210-570-0214
Fax Number	:

Provider Business Practice Location Address
First Line	:	4204 GARDENDALE ST STE 107
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3138
Country	:	US
Telephone Number	:	210-334-0108
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2025
Last Update Date	:	12/11/2025

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